GENERAL RULES by liaoqinmei

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									                                            INGHAM REGIONAL MEDICAL CENTER
                                                  PROFESSIONAL STAFF

                                                                    GENERAL RULES


ARTICLE I. SPECIAL DEFINITIONS...................................................................................................................4

ARTICLE II. ADMISSION AND DISCHARGE OF PATIENTS.........................................................................4
   2.1      GENERAL PROVISIONS REGARDING PATIENT ADMISSION ........................................................4
   2.2      PRACTITIONER RESPONSIBILITIES ...................................................................................................4
      2.2-1   Care Treatment and Documentation .....................................................................................................4
      2.2-2   Patient Management ..............................................................................................................................4
   2.3      EMERGENCY MEDICAL SCREENING, EMERGENCY ADMISSIONS AND ON CALL
   RESPONSIBILITY ..................................................................................................................................................5
      2.3-1   Emergency Medical Screening Obligation Generally ...........................................................................5
      2.3-2   On-Call Procedures and Responsibilities for Members ........................................................................5
      2.3-3   Responsibilities of Departments ............................................................................................................6
      2.3-4   Responsibilities of the Emergency Department .....................................................................................6
      2.3-5   Process for Reporting And Investigation of On Call Protocol Violations .............................................6
   2.4      PATIENT TRANSFERS............................................................................................................................7
      2.4-1   Internal Patient Transfers......................................................................................................................7
      2.4-5   External Patient Transfers.....................................................................................................................7
   2.5      SPECIAL PROVISIONS FOR PATIENT CONDITIONS OF A PSYCHIATRIC NATURE ..................8
           (a)       Restraint/Seclusion................................................................................................................................................. 8
           (b)       Electroconvulsive Therapy ..................................................................................................................................... 8
           (c)       Behavior Modification Techniques......................................................................................................................... 9
           (d)       Treatment for Children and Adolescents ................................................................................................................ 9
   2.6           ADMISSION TO SPECIALIZED CARE UNITS .....................................................................................9
           (a)       Critical Care Units................................................................................................................................................. 9
           (b)       Geropsychiatric Unit .............................................................................................................................................. 9
           (c)       Medical Rehabilitation Unit ................................................................................................................................... 9
           (d)       Step-Down Units..................................................................................................................................................... 9
   2.7           ADMISSION TO PROVIDER BASED CARE UNITS ............................................................................9
   2.8           DOCUMENTATION OF CONTINUED HOSPITALIZATION.............................................................10
   2.9           DISCHARGE OF PATIENTS .................................................................................................................10
   2.10          RELEASE OF DECEASED PATIENTS .................................................................................................10
   2.11          AUTOPSIES ............................................................................................................................................11
   2.12          MEDICAL EXAMINER CASES.............................................................................................................11
ARTICLE III. MEDICAL RECORDS...................................................................................................................11
   3.1           CONTENTS OF THE MEDICAL RECORD ..........................................................................................11
           (a)   Identification data; ............................................................................................................................................... 12
           (b)   Medical history;.................................................................................................................................................... 12
           (c)   Physical examination; .......................................................................................................................................... 12
           (d)   Diagnostic and therapeutic orders; ...................................................................................................................... 12
           (e)   Evidence of appropriate informed consent that shall include a description of the procedure, benefits and risk to
           include the patient’s (or guardian’s), proceduralist’s and Practitioner’s signature.......................................................... 12
           (f)   Clinical observations, including results of therapy; ............................................................................................. 12
           (g)   Reports of procedures, operations, tests, and results thereof; .............................................................................. 12
           (h)   Consultation reports when applicable;................................................................................................................. 12
           (i)   Autopsy report when appropriate;........................................................................................................................ 12
           (j)   Detailed discharge instructions; and .................................................................................................................... 12
           (k)   A discharge summary at termination of hospitalization to include principal diagnoses, secondary diagnoses if
PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11                                   R1
           appropriate, and prognostics. ......................................................................................................................................... 12
   3.2           HISTORY AND PHYSICAL REQUIREMENT AND CONTENTS ......................................................12
           (a)     Identifying Data.................................................................................................................................................... 12
           (b)     Presenting Complaint and History of Present Illness........................................................................................... 12
           (c)     Past Medical and Surgical History....................................................................................................................... 12
           (d)     Allergies ............................................................................................................................................................... 12
           (e)     Medications .......................................................................................................................................................... 12
           (f)     Social History and Habits .................................................................................................................................... 13
           (g)        Review of Systems ........................................................................................................................................... 13
           (h)     Immunization status.............................................................................................................................................. 13
           (i)     Required components for special populations include: ........................................................................................ 13
               (i)    Pediatric patients ............................................................................................................................................ 13
               (ii) Patients undergoing any invasive procedure .................................................................................................. 13
               (iii)      All Osteopathic Physicians shall record a musculoskeletal examination .................................................. 13
           (j)     Assessment and Plan ............................................................................................................................................ 13
      3.2-5        Obstetrical Patients: ............................................................................................................................14
   3.3           HISTORY AND PHYSICAL ON CHART PRIOR TO SURGERY .......................................................14
   3.4           DATE AND SIGNATURE REQUIREMENT FOR ATTENDING PRACTITIONER...........................14
   3.5           PROGRESS NOTES ................................................................................................................................14
   3.6           OPERATIVE AND PROCEDURE REPORTS .......................................................................................15
   3.7           CONSULTATION REPORTS.................................................................................................................15
   3.8           USE OF SYMBOLS/ABBREVIATIONS IN MEDICAL RECORD ......................................................15
   3.9           DISCHARGE SUMMARY......................................................................................................................15
   3.10          ACCESS TO MEDICAL RECORDS/INFORMATION .........................................................................15
   3.11          FINAL DISPOSITION OF MEDICAL RECORD...................................................................................16
   3.12          COMPLETION OF MEDICAL RECORDS............................................................................................16
   3.13          SUSPENSION OF PRIVILEGES ............................................................................................................16
ARTICLE IV. GENERAL CONDUCT OF CARE ...............................................................................................17
   4.1           PATIENT CONSENT FOR TREATMENT ............................................................................................17
      4.1-4        Surgical Consent..................................................................................................................................17
   4.2           WRITTEN AND VERBAL ORDERS .....................................................................................................18
      4.2-5        Persons Able to Accept and Transcribe Oral Orders ..........................................................................19
   4.3           FORM OF WRITTEN ORDERS/RE-WRITTEN ORDERS ...................................................................19
   4.4           CONTROL OF DRUG ADMINISTRATION .........................................................................................19
      4.4-2        Automatic Expiration of Orders...........................................................................................................19
   4.5           CONSULTATIONS .................................................................................................................................20
      4.5-2        Consultation is required in the following situations:...........................................................................20
      4.5-3        Except in an emergency, consultation is encouraged in the following situations: ..............................20
      4.5-4        Form of Consultations .........................................................................................................................21
           (a)       Consultation Only................................................................................................................................................. 21
           (b)       Consultation and Concurrent Care ...................................................................................................................... 21
           (c)       Consultation and Complete Referral .................................................................................................................... 21
   4.6           SUPERVISION OF HOUSE OFFICERS ................................................................................................21
ARTICLE V. GENERAL RULES REGARDING SURGICAL CARE ..............................................................21
   5.1      AUTOMATIC CANCELLATION OF SURGICAL PROCEDURE .......................................................21
   5.2      CARE OF GENERAL DENTAL PATIENTS .........................................................................................21
      5.2-1   Dentist’s Responsibilities.....................................................................................................................22
      5.2-2   Physician’s Responsibilities.................................................................................................................22
      5.2-3   Discharge of Dental Patients...............................................................................................................22
   5.3      CARE OF PODIATRIC PATIENTS .......................................................................................................22
      5.3-1   Podiatrist's Responsibilities.................................................................................................................22
      5.3-2   Physician's Responsibilities .................................................................................................................23


PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11                                    R2
ARTICLE VI. EMERGENCY SERVICES ...........................................................................................................23
   6.1           PHYSICIAN STAFFING.........................................................................................................................23
   6.2           MEDICAL RECORD FOR EMERGENCY PATIENTS.........................................................................23
   6.3           DISASTER PLANNING..........................................................................................................................24
ARTICLE VII. PROVISIONS FOR USE OF ANESTHETIC AGENTS ...........................................................24
   7.1      USE OF LEVEL I MEDICATIONS ........................................................................................................24
   7.2      USE OF LEVEL II ANESTHESIA MEDICATIONS .............................................................................24
      7.2-1   Definition .............................................................................................................................................24
           (a)       Narcotics (Opioids) .............................................................................................................................................. 24
           (b)       Specified barbiturates(Emergency Department only)........................................................................................... 24
           (c)       Benzodiazepines ................................................................................................................................................... 24
           (d)       Dissociative Agents (Emergency Department only) ............................................................................................. 24
           (e)       Profofal ................................................................................................................................................................ 24
           (f)       Chloral Hydrate (Emergency Department and Pediatrics only) .......................................................................... 24
       7.2-2         Designated Areas/Facility Support......................................................................................................24
           (a)       Surgery - Main Operative Suites .......................................................................................................................... 25
           (b)       Surgery - Arthroscopic Surgery Center ................................................................................................................ 25
           (c)       Endoscopy Unit .................................................................................................................................................... 25
           (d)       Bronchoscopy Procedure Room ........................................................................................................................... 25
           (e)       Special Studies Unit (Cath Lab) ........................................................................................................................... 25
           (f)       Radiology Department.......................................................................................................................................... 25
           (g)       Emergency Department ........................................................................................................................................ 25
           (h)       Special Care Units (CICU, Pre/Post Cath Unit) .................................................................................................. 25
       7.2-3         Credentialing Responsibility................................................................................................................25
           (a)       Department of Anesthesiology.............................................................................................................................. 25
           (b)       Other Professional Staff Departments.................................................................................................................. 25
      7.2-4   Medico-Administrative Responsibilities ..............................................................................................25
      7.2-5   Administration .....................................................................................................................................25
   7.3      USE OF ANESTHESIA OUTSIDE THE SCOPE OF LEVELS I AND II .............................................26
      7.3-1   Credentialing Responsibility................................................................................................................26
      7.3-2   Other Considerations...........................................................................................................................26
ARTICLE VIII. PROFESSIONAL STAFF MEETINGS.....................................................................................26
   8.1           ANNUAL MEETING ..............................................................................................................................26
   8.2           REGULAR PROFESSIONAL STAFF MEETINGS ...............................................................................26
ARTICLE IX. DEPARTMENT/SECTION RULES ..............................................................................................26
   9.1           DEPARTMENT/SECTION RULES........................................................................................................26
ARTICLE X. ADOPTION AND AMENDMENT .................................................................................................27
   10.1     PROFESSIONAL STAFF RESPONSIBILITY AND BOARD INITIATION ........................................27
   10.2     AMENDMENT ........................................................................................................................................27
   10.3     ADOPTION..............................................................................................................................................27
      10.3-1    Professional Staff ............................................................................................................................27




PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11                                     R3
                                    INGHAM REGIONAL MEDICAL CENTER
                                          PROFESSIONAL STAFF

                                                  GENERAL RULES

                                         ARTICLE I. SPECIAL DEFINITIONS
1.1        As used in these Rules, and only when appropriate to the context, the term "Practitioner" includes a Nurse
           Midwife who has delineated Specified Service Authority (limited privileges) to admit patients and manage
           their care as prescribed in Special Policy For Allied Health Professionals (AHPs) of the Bylaws and
           appropriate departments' rules and policies. In all other instances, the definitions set forth in the Bylaws
           shall apply to these Rules.


                     ARTICLE II. ADMISSION AND DISCHARGE OF PATIENTS
2.1        GENERAL PROVISIONS REGARDING PATIENT ADMISSION

           2.1-1      The Hospital shall admit all patients for which it is properly equipped to provide care, which shall
                      include the availability of beds.

           2.1-2      A patient may be admitted to the Hospital only by a Practitioner. All Practitioners shall be
                      governed by the official admitting policy of the Hospital and/or special units that may from time
                      to time be amended or modified.

           2.1-3      No patient shall be admitted to the Hospital until a provisional diagnosis or a valid reason for
                      admission has been stated. In the case of an emergency, such statement shall be recorded as soon
                      as possible.

2.2        PRACTITIONER RESPONSIBILITIES

           2.2-1      Care Treatment and Documentation

                      A Member shall be responsible for the medical care and treatment of each patient in the Hospital,
                      for daily observation of the patient (except as may otherwise be required by a Special Care Unit
                      consistent with State and Federal regulations), for the prompt completion and accuracy of the
                      medical record, for necessary special instructions, and for transmitting reports of the condition of
                      the patient to the patient and/or his relative or legally responsible person and to the referring
                      Practitioner.

           2.2-2      Patient Management

                      (a)        All Practitioners shall cause their patients to have twenty-four (24) hour coverage while
                                 in the Hospital. Should the Practitioner be unavailable, it is his responsibility to make
                                 appropriate arrangements with another Practitioner to continue the care for his patients.

                      (b)        Should a Practitioner fail to name such an alternative Practitioner, the CEO, the Co-
                                 Chief(s), or Chairman of the Department or Section concerned shall have authority to call
                                 any Member of the Active Staff with comparable Privileges to assume the care of the
                                 patient. The CEO will notify the attending Practitioner.

                      (c)        If the attending Practitioner transfers the care of a patient to another Practitioner, the
PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11           R4
                                 attending Practitioner shall indicate on the order sheet the name of the Practitioner who
                                 shall be assuming management of the patient.

                      (d)        All Practitioners shall accept the responsibility to respond to requests for assistance when
                                 the quality and/or appropriateness of the care being provided to a particular patient are in
                                 question.

                      (e)        If a Practitioner believes patient care is in jeopardy because of actions or inaction’s of
                                 another Practitioner, he/she shall notify the Chairman of the Department of the second
                                 Practitioner. If a Chairman is unavailable, he shall notify the Co-Chiefs, VPMA, the
                                 Vice Chairman of the second Practitioner's Department, or the CEO. Quality concerns
                                 shall be referred to the appropriate Professional Staff Department for review.

2.3        EMERGENCY MEDICAL SCREENING, EMERGENCY ADMISSIONS AND ON CALL
           RESPONSIBILITY

           2.3-1      Emergency Medical Screening Obligation Generally

                     (a)         The Hospital is obligated and shall provide, upon request and within its capabilities,
                                 appropriate medical screening examination, stabilizing treatment and/or an appropriate
                                 transfer to another medical facility to any individual with an emergency medical
                                 condition, regardless of the individual’s eligibility for Medicare, in accordance with the
                                 Emergency Medical Treatment and Labor Act (EMTALA).

                     (b)         The medical screening examination, in accordance with current Hospital policy, may be
                                 performed by a Physician and/or by such other medical personnel as are delegated by the
                                 supervising Physician and deemed qualified to determine the presence or absence of an
                                 emergency medical condition.

                      (c)        Any Practitioner with on call responsibilities requested to provide emergency medical
                                 treatment must respond in a timely manner, or personally arrange for an appropriate
                                 alternative Practitioner to timely provide emergency treatment for patients in the
                                 Emergency Department, inpatients requiring emergency specialty consultation or patients
                                 in labor. Failure to meet this obligation may result EMTALA consequences for the
                                 Hospital and the offending Practitioner.

           2.3-2      On-Call Procedures and Responsibilities for Members

                      (a)        Consistent with Bylaws Section 4.4, each Active, Adjunct and in certain circumstances
                                 Affiliate Professional Staff Member is responsible for on-call service as assigned by his
                                 Department Chairman.

                      (b)        When an on-call Practitioner is contacted by an attending Department Practitioner or is
                                 unable to provide care, it is the on-call Practitioner’s responsibility to contact another
                                 appropriate Practitioner to assume the care, and to inform the Emergency Department
                                 Practitioner or inpatient attending of the arrangement.

                      (c)        The on-call Practitioner, or his designee, is expected to respond within thirty (30) minutes
                                 when requested to appear personally.




PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11            R5
                      (d)        If the on-call Practitioner and the Emergency Department attending Physician or inpatient
                                 attending disagree as to the disposition or plan of care of the patient, the on-call
                                 Practitioner will appear within thirty (30) minutes to personally evaluate the patient.

                      (e)        If the on-call Practitioner cannot fulfill his call responsibilities for any reason, it is his
                                 responsibility to find an appropriate alternate and to notify the Emergency Department
                                 attending Physician or inpatient attending of the alternate(s), coverage dates and times.

                      (f)        If a Practitioner fails to respond to an on-call service request in a timely manner, the
                                 behavior will be reported to the Department Chairman of the Member. The Practitioner
                                 will be available within two (2) business days of a request to meet with the VPMA, Co-
                                 Chief(s) of the Professional Staff, or designee when the responsibilities outlined in this
                                 protocol are under investigation. If successive infractions of on-call coverage occur, the
                                 Member may be:

                                 (i)         referred to the Quality Improvement Committee of his/her Department.

                                 (ii)        referred to the Professional Staff Executive Committee.

                                 (iii)       made subject to other disposition according to the disruptive behavior protocol.

                      (g)        In the event the on-call Practitioner disagrees with the conclusion of the Emergency
                                 Department attending Physician or inpatient attending Practitioner that his presence is
                                 immediately required, he shall nevertheless come to the Hospital in accordance with the
                                 timeframes outlined in this protocol. He may, however, request the VPMA or designee
                                 to review the case.

           2.3-3      Responsibilities of Departments

                      (a)        Each Department Chairman is responsible for assignment of on call duties. He must
                                 ensure that all specialties and sub-specialties in his Department are covered by an on call
                                 Practitioner and his Department’s Members fulfill their obligations.

                      (b)        The on-call schedule will be provided to the Emergency Department and the CEO or his
                                 designee in no less than one-month increments.

           2.3-4      Responsibilities of the Emergency Department

                      (a)        All pertinent information pertaining to the patient must be available to the on call
                                 Practitioner for evaluation. The information shall be faxed to the office of the on call
                                 Practitioner for appropriate outpatient follow up when indicated.

           2.3-5      Process for Reporting and Investigation of On Call Protocol Violations

                      (a)        If a Professional Staff Member fails to respond to an on call service request in a timely
                                 manner, this will be reported immediately to his Department Chairman or, if he is not
                                 available, Medical Administration will arrange for evaluation and/or care of the patient.
                      (b)        The Emergency Department attending Physician or inpatient attending Practitioner will
                                 immediately notify Risk Management or the on call administrator if:

                                 (i)         An on call Practitioner refuses to timely come in; and

                                 (ii)        A substitute Practitioner cannot be found; and

PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11              R6
                                 (iii)       The patient is or may be transferred to another facility as a result of this.

                      (c)        If patient care was provided by another Practitioner because the on call Practitioner failed
                                 to respond, the Emergency Department attending Physician or inpatient attending
                                 Practitioner will notify Risk Management the next business day.

                      (d)        Risk Management and Compliance, in conjunction with Medical Administration, will
                                 investigate any occurrence related to a potential or actual violation of the on call protocol
                                 in a timely manner when EMTALA rules appear to be infracted.

                      (e)        Violations of the on call protocol will be referred to the Practitioner’s Departmental
                                 Quality Improvement Committee. The committee’s disposition of the issue will be done
                                 in accordance with the provisions of the Professional Staff Bylaws, Appendices, Rules
                                 and Policies.

           2.3-6      Patients who are admitted on an emergency basis and do not have an established relationship with
                      a Practitioner will be assigned to the care of a Member on call. The Chairman of each Department
                      shall provide a schedule for such assignments to the Department of Emergency Medicine and to
                      the CEO.

2.4        PATIENT TRANSFERS

           2.4-1      Internal Patient Transfers

                      Transfer priorities shall be:

                      (a)        The emergency patient to an appropriate inpatient bed;

                      (b)        To a special care unit from another inpatient area if unit admission criteria are met or by
                                 approval of the special care unit director; or

                      (c)        From a special care unit to a general care unit whenever level of necessary care does not
                                 meet unit criteria.

           2.4-2      Transfers from one Hospital campus to another shall be considered internal patient transfers but
                      shall only be made if the patient is stable or the perceived benefits of the transfer outweigh the
                      apparent risks of transfer.

           2.4-3      In transferring patients (to/from service areas), the approval of the responsible Practitioner will be
                      obtained whenever possible. When there is a conflict regarding patient placement, consultation
                      shall take place between the appropriate Practitioner, Administration, and Nursing personnel.

           2.4-4      Patients will be discharged from acute care units and admitted to Medical Rehabilitation and
                      Geropsychiatry. Likewise, patients will be discharged from Medical Rehabilitation and
                      Geropsychiatry, and admitted to the acute care units.

           2.4-5      External Patient Transfers

                      (a)        The attending Practitioner is responsible for transfer arrangements to another hospital
                                 and/or Practitioner and the patient or his/her surrogate decision maker. These transfers
                                 should be made in compliance with Hospital policies.



PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11               R7
                      (b)        Arrangements for transfers to extended care facilities or nursing homes will be completed
                                 by the Hospital personnel in conjunction with the attending Practitioner and the patient or
                                 his/her surrogate decision maker.

2.5        SPECIAL PROVISIONS FOR PATIENT CONDITIONS OF A PSYCHIATRIC NATURE

           2.5-1      The admitting Practitioner shall be held responsible for obtaining and providing such information
                      as may be necessary to minimize risk to the patient from self-harm and to minimize risk to others
                      whenever the patient might be a source of danger for any reason.

           2.5-2      For the protection of patients, the medical and nursing staffs, other employees, and the Hospital,
                      the following principles are to be met in the case of the potentially suicidal patient regardless of
                      placement in the Hospital.

                      (a)        Any patient known or suspected to be suicidal in intent shall be admitted to appropriate
                                 accommodations in the Hospital. In the event such accommodations are not available,
                                 the patient should ordinarily be transferred to another facility with available appropriate
                                 accommodations.

                      (b)        Any patient known or suspected to be suicidal or who has recently attempted suicide shall
                                 be seen by a Member of the Department of Psychiatry within twenty-four (24) hours.

                                 Exception: For pediatric consultations in cases of overdose or suicide, if a child
                                 psychiatrist is unavailable, an AHP credentialed child psychologist may be called to
                                 accomplish the consultation while the patient is in the Hospital. A consultation note with
                                 specific reference to future management shall be written/dictated.

           2.5-3      Any Practitioner may admit a patient to the inpatient psychiatric units; however, all patient
                      admissions must be approved for appropriateness as soon as possible by the Medical Director(s) of
                      the psychiatric units.

           2.5-4      The management of all patients admitted to the psychiatric units shall be consistent with
                      requirements of the Michigan Department of Mental Health and the Policies and Procedures
                      established for patients admitted to the psychiatric units and approved by the Professional Staff.

           2.5-5      Certain special treatment procedures for psychiatric patients require specific documentation and/or
                      consultation as delineated below:

                      (a)        Restraint/Seclusion

                                 Restraints/seclusion shall be ordered only consistent with Hospital policy guided by the
                                 Medicare Conditions of Participation and state law. In this regard:

                                 (i)         Hospital policy shall specify the time within which an order must be obtained
                                             after each use of restraint or seclusion and the maximum time for the use of
                                             either intervention.

                                 (ii)        Hospital policy shall address periodic observation of patients for whom restraint
                                             or seclusion is employed, including a maximum time between observations.
                                             Physician orders shall not specify a length of time between observations that is
                                             greater than that specified in Hospital policy.

                      (b)        Electroconvulsive Therapy
                                 Prior to the administration of electroconvulsive therapy or other forms of convulsive
PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11              R8
                                 therapy to adults or adolescents, the concurrence of two psychiatrists, who shall examine
                                 and consult with the Physician responsible for the patient and make the appropriate
                                 documentation in the record, is required. In the event of children, at least one (1)
                                 consulting psychiatrist must be a child psychiatrist.

                      (c)        Behavior Modification Techniques
                                  Specific documentation justifying the use of aversive conditioning in emotional, mental,
                                 or behavioral disorders is required.

                      (d)        Treatment for Children and Adolescents
                                 All special treatment procedures for children and adolescents require a consultation by a
                                 child psychiatrist.

2.6        ADMISSION TO SPECIALIZED CARE UNITS

           2.6-1      Rules for the operation of specialized units, included, but not limited to, the special care units,
                      shall be formulated by the appropriate committees of the Professional Staff in accordance with
                      Hospital Staff subject to approval by the PSEC.

                      This rule as stated above is applicable, but not limited to the following special care units:

                      (a)        Critical Care Units

                      (b)        Geropsychiatric Unit

                      (c)        Medical Rehabilitation Unit

                      (d)        Step-Down Units

           2.6-2      Only patients meeting the respective admission/continued-stay criteria as approved by the
                      Professional Staff for designated special care areas may be admitted to such specified units.

           2.6-3      If questions as to appropriateness of an admission to or transfer from a special care unit should
                      arise, the Medical Director or other designated individual as defined in the unit's respective criteria
                      will be consulted. The admitting Practitioner will be consulted whenever possible, but the
                      Medical Director or other designated person shall have discretionary authority to transfer the
                      patient if deemed appropriate. If, for some reason, the Medical Director or his designee cannot be
                      consulted, the Department Chairman of the Practitioner or his appropriate representative, or Co-
                      Chief(s) may administratively validate a transfer.

2.7        ADMISSION TO PROVIDER BASED CARE UNITS

           2.7-1      Rules for the operation of provider based care units shall be formulated by the appropriate
                      committees of the Professional Staff with such rules subject to approval of the PSEC.

                      This rule as stated above is applicable, but not limited to the following provider based care units:
                      ESRD Center

           2.7-2      Only patients meeting the respective admission criteria as approved by the Professional Staff for
                      designated provider based care areas may be admitted to such specified units.

           2.7-3      If questions as to appropriateness of an admission to or transfer from a provider base care unit
                      should arise, the Medical Director or other designated individual as defined in the unit's respective
                      criteria will be consulted. The admitting Practitioner will be consulted whenever possible, but the
PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11           R9
                      Medical Director or other designated person shall have discretionary authority to transfer the
                      patient if deemed appropriate. If, for some reason, the Medical Director or his designee cannot be
                      consulted, the Department Chairman of the Practitioner or his appropriate representative, or Co-
                      Chief(s) may administratively validate a transfer.

2.8        DOCUMENTATION OF CONTINUED HOSPITALIZATION

           2.8-1      An attending Practitioner is required to document on a daily basis the continuing care of the
                      patient from direct personal observation of the patient. This documentation should contain at a
                      minimum:

                      (a)        Information reflecting the patient’s current condition and the continuing plan of care;

                      (b)        Indication of any changes that may alter the estimated length of stay, if applicable;

                      (c)        Indication that discharge planning (if applicable) is being coordinated; and

                      (d)        Date, time, and signature of the Practitioner making the observation.

                      EXCEPTION: Special Care Units or Provider Based Care Units may develop other guidelines
                      consistent with State and Federal regulations and accreditation requirements. Failure to develop
                      other guidelines shall mean the specific Special Care Units or Provider Based Care Units is to be
                      governed by this section.

           2.8-2      Upon request of the committee charged with the utilization review function, the attending
                      Practitioner must provide additional written information justifying continued hospitalization as
                      indicated following review of the record. Failure to comply with this policy will be brought to the
                      attention of the PSEC for appropriate action.

2.9        DISCHARGE OF PATIENTS

           2.9-1      Patients shall be discharged only upon order of a Practitioner. Should a patient leave the Hospital
                      against the advice of the attending Practitioner or without proper discharge, the events should be
                      documented according to Hospital policy and procedure. At a minimum, a notation of the incident
                      shall be made in the medical record indicating the patient was advised against leaving the Hospital
                      and the reasons therefore.

           2.9-2      It shall be the responsibility of the attending Practitioner or designee to discharge his patients as
                      expediently as possible.

           2.9-3      Practitioners should initiate discharge planning as soon as possible after admission.

           2.9-4      Discharge of Dental and Podiatric patients shall be governed by Sections 5.2 and 5.3 of these
                      Rules.

2.10       RELEASE OF DECEASED PATIENTS

           In the event of an in-hospital death, the deceased shall be pronounced by the attending Practitioner or his
           designee within a reasonable time. The body shall not be released until an appropriate entry has been made
           in the record by the Practitioner or designee who pronounced death. Notification of the family and
           disposition of the body shall be made in compliance with Hospital policy.



PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11           R 10
2.11       AUTOPSIES

           An autopsy may be performed only with written consent of the next of kin or legal guardian, except in
           cases involving the Medical Examiner where consent is established by law. All autopsies shall be
           performed by the Hospital’s Pathology Department unless otherwise directed by the Medical Examiner.
           Provisional anatomic diagnoses shall be recorded on the medical record within seventy-two (72) hours, and
           the complete findings shall be made a part of the record within sixty (60) calendar days except for
           toxicology reports.

           Toxicology reports must be on the chart within six (6) months. The results of autopsies shall be used as a
           source of clinical information for quality assessment/improvement purposes. Members of the Professional
           Staff are strongly encouraged to obtain an autopsy in cases of deaths in the Surgical Suites, deaths within
           twenty-four (24) hours of surgery/invasive procedures, any unexpected death, and any death where the
           cause of death is unknown

2.12       MEDICAL EXAMINER CASES

           The Medical Examiner must be notified of a patient death that by law is classified as reportable. Reportable
           deaths include the following types:

             (a)        All deaths by violence, whether accidental or purposeful, self-inflicted, or caused by another
                        person. The passage of time between the injury and death does not alter the reporting
                        requirement;

             (b)        Sudden, unexpected deaths of persons believed to be in good health where no history of major
                        medical problems or progressive disease can be determined; and

             (c)        Any other death where no definitive causes can be determined.

             The Nursing Supervisor on duty shall coordinate notice to the Medical Examiner's office on reportable
             cases. All Medical Examiner cases shall be released from the Hospital only on the authority of the
             Medical Examiner.

                                         ARTICLE III. MEDICAL RECORDS
3.1        CONTENTS OF THE MEDICAL RECORD

           3.1-1      The attending Practitioner shall be responsible for the preparation of a complete, current, accurate,
                      pertinent, and legible permanent medical record for each of his patients.

                      a)         In the event of a Member's death or other situations where the Member may be unable to
                                 provide care to patients, where associates of the Member exist as Members of the Staff,
                                 the associates shall be expected to assist in completing medical records and assumption
                                 of the care of any inpatients, as qualified. Otherwise, the appropriate Department and/or
                                 Committee Chairman and/or a Co-Chief of the Professional Staff shall assume such
                                 responsibilities.




PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11          R 11
           3.1-2      This medical record shall contain:

                      (a)        Identification data;

                      (b)        Medical history;

                      (c)        Physical examination;

                      (d)        Diagnostic and therapeutic orders;

                      (e)        Evidence of appropriate informed consent that shall include a description of the
                                 procedure, benefits and risk to include the patient’s (or guardian’s), proceduralist’s and
                                 Practitioner’s signature.

                      (f)        Clinical observations, including results of therapy;

                      (g)        Reports of procedures, operations, tests, and results thereof;

                      (h)        Consultation reports when applicable;

                      (i)        Autopsy report when appropriate;

                      (j)        Detailed discharge instructions; and

                      (k)        A discharge summary at termination of hospitalization to include principal diagnoses,
                                 secondary diagnoses if appropriate, and prognostics.

                      NOTE: The format in which this information is recorded may vary among units especially on the
                      Special Care Units.

           3.1-3      All entries in the patient's medical record shall be accurately dated, timed, and signed by the
                      writer.

3.2        HISTORY AND PHYSICAL REQUIREMENT AND CONTENTS

           3.2-1      An admission medical history and physical examination shall be recorded within twenty-four (24)
                      hours. Each Professional Staff Department will determine specific content requirements based
                      upon its scope of practice, but all records should include:

                      (a)        Identifying Data
                                 Patient's name, record number and name of the primary care Physician.

                      (b)        Presenting Complaint and History of Present Illness
                                 A thorough review of the involved (or potentially involved) system(s), relevant life-style,
                                 occupational or exposure risk factors and family history.

                      (c)        Past Medical and Surgical History

                      (d)        Allergies

                      (e)        Medications



PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11            R 12
                      (f)        Social History and Habits
                                 A brief review of the patient’s occupational status, living situation and stressors and any
                                 data relevant to cultural/spiritual needs of the patient. Habits, which may impact
                                 negatively on the patient’s immediate course, should be listed.

                      (g)        Review of Systems
                                 If a condition other than the primary admitting condition is found or suspected which
                                 might impact on the patient's immediate course, a complete review of the involved
                                 system(s) should be recorded. All patients undergoing an invasive procedure who have a
                                 history of significant medical problems shall have a review of the involved system(s)
                                 recorded.

                      (h)        Immunization status
                                 (Required for all pediatric patients.)

                      (i)        Required components for special populations include:

                                 (i)         Pediatric patients
                                             Developmental age, weight, length/height and head circumference.

                                 (ii)        Patients undergoing any invasive procedure
                                             Mental status.

                                 (iii)       All Osteopathic Physicians shall record a musculoskeletal examination in
                                             accordance with the American Osteopathic Association accreditation
                                             requirements. If a musculoskeletal examination is contraindicated the reason
                                             shall be recorded.

                      (j)        Assessment and Plan
                                 A statement of the active and relevant diagnoses and a plan of evaluation and treatment
                                 including appropriateness of setting for care rendered.

                                 (i)         For pediatric patients consideration of educational/daily activity needs must be
                                             documented.

                                 (ii)        For patients who are victims of alleged or suspected abuse or neglect:

                                 (iii)       The assessment is conducted with the consent of the patient or parent or legal
                                             guardian or as otherwise provided by law.

                                 (iv)        The assessment is conducted in accordance with the organization’s
                                             responsibility for the collection, retention, and the safeguarding of evidentiary
                                             material released by the patient.

                                 (v)         The assessment includes, as legally required, the notification and release of
                                             information to the proper authorities.

           3.2-2      If a completed history has been obtained and a physical examination performed within thirty (30)
                      calendar days prior to admission by a Member, a durable, legible copy of these reports may be
                      used in the patient's hospital medical record provided there is an update to the history and
                      physical documented in the record within twenty-four (24) hours of admission. The admission
                      history and physical may also serve as a preoperative history and physical for any surgical
                      procedure performed during the admission.

PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11              R 13
           3.2-3      When a patient is readmitted within thirty (30) calendar days for the same or related problem, an
                      interval history and physical examination reflecting any subsequent changes may be used in the
                      medical record, provided the original is readily available to the Practitioner.

           3.2-4      If the admitting Practitioner later transfers the patient to the care of another Practitioner, the
                      admitting Practitioner shall remain responsible for the history and physical and a mandatory
                      admitting progress note.

           3.2-5      Obstetrical Patients:

                      Properly executed prenatal forms, which have been approved by the Hospital, may be used in lieu
                      of a history and physical progress note provided that the form is submitted to the Obstetrical
                      Department prior to delivery. The attending Practitioner shall still be responsible for the
                      completion of an interval history and physical within twenty-four (24) hours after admission.

           3.2-6      All or part of the history and physical may be delegated to other practitioners, in accordance with
                      State Law and hospital policy, but the Practitioner must sign, date and time the history and
                      physical and as applicable, the update note and assume full responsibility for its contents. For
                      example, a Nurse Practitioner or Physician Assistant may perform the history and physical, and
                      the update assessment and note, but both must be co-signed by the attending/covering Practitioner.

3.3        HISTORY AND PHYSICAL ON CHART PRIOR TO SURGERY

           The medical history and physical examination shall be on the chart before performance of a surgical
           operation, invasive procedure or procedure requiring anesthesia consistent with anesthesia guidelines.
           Failure to so record may result in cancellation of the operative procedure unless the attending Practitioner
           states in writing that such delay would be dangerous to the patient. The Nursing Supervisor on duty shall
           notify the Chairman of the Department or Section Chairman of the operating Practitioner, or his designee,
           which shall have the authority to cancel a procedure under these circumstances.

3.4        DATE AND SIGNATURE REQUIREMENT FOR ATTENDING PRACTITIONER

           The attending Practitioner shall date, sign, and/or countersign the history, physical examination, operative
           report, consultation, and discharge summary when they have been recorded by a member of the House
           Staff, which includes but is not limited to, medical students, House Officers (interns, residents, and fellows)
           or when recorded by those AHPs who have been granted the authority to record entries in the medical
           record. Medical record entries made or dictated by the House Officer or an AHP shall be signed by such
           person. The attending Practitioner shall review, date and sign the history and physical examination when it
           has been provided by a physician who has not been granted these privileges by the Board.

           Exception: Entries made by Dentists or Podiatrists shall be governed by Sections 5.2 and 5.3 of these
           Rules and by the Bylaws.

3.5        PROGRESS NOTES

           Progress notes shall be recorded, dated, timed, and signed by all attending Practitioners or an appropriately
           credentialed AHP at least daily. The mandatory admitting progress note should state the chief complaint,
           the symptoms and physical findings that led to a working diagnosis, the expected therapy, and possible
           consultation. There should be a pertinent chronological report of the patient's hospital course including
           significant physical changes, new signs and symptoms, complications, consultations, treatment, and results
           of that treatment. Each of the patient's clinical problems should be clearly identified.

           Pertinent progress notes may also be made by others so authorized to make entries in the medical record,
           such as medical students, House Officers, and AHPs who have been granted such authority. The attending
PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11         R 14
           Practitioner is responsible for authenticating such entries where applicable. Recording of progress notes by
           such persons does not relieve the attending Practitioner of his responsibilities under Section 3.1.

3.6        OPERATIVE AND PROCEDURE REPORTS

           Operative and procedure reports should be dictated or written by the operating Practitioner or House
           Officer under the direction of the operating Practitioner in the medical record immediately after surgery and
           shall include a detailed description of the procedure, the findings, the specimens removed, the postoperative
           diagnosis, and the name of the primary surgeon and any assistants. All operative reports, including
           outpatient surgery procedures, shall be dictated within twenty-four (24) hours of the procedure and signed
           as soon as possible following transcription. All such reports shall be made a part of the current medical
           record.

3.7        CONSULTATION REPORTS

           Consultations shall show evidence of the consultant's review of the patient's current medical record and
           prior records, if relevant; pertinent findings on examination of the patient; his opinion based on review and
           examination; and his recommendations. This report shall be made a part of the patient's medical record.
           The recommendations of the consultant shall be entered on the chart immediately upon completion of the
           consultation. When operative procedures are involved, the consultation note shall, except in emergency
           situations so verified in the record, be recorded prior to the operation. The consultant shall sign the
           consultation report and record the date and time of the consultation.

3.8        USE OF SYMBOLS/ABBREVIATIONS IN MEDICAL RECORD

           Symbols/abbreviations should not be used in the final diagnosis or on the face sheet of the patient's record.
           The use of symbols/abbreviations is discouraged in any documentation related to patient care, treatment, or
           orders except for those abbreviations established by the Medical Records Committee and placed in the
           Medical Record Department's glossary.

3.9        DISCHARGE SUMMARY

           Except as provided below, a discharge summary shall be written or dictated on all patients hospitalized.
           The content of this summary shall describe the hospital stay including any complications that developed,
           condition on discharge (whether there was a resolution of the admission diagnosis and chief complaint),
           determination of whether the diagnosis and treatment were justified or whether a diagnosis could not be
           established, the disposition of the case, and termination of the Practitioner's responsibility. The summary
           shall be sufficient to justify the diagnosis, warrant the treatment rendered, indicate the end result, assess
           condition of patient on discharge, and, if applicable, postoperative instructions to the patient including the
           recommended time for a return visit and to whom. All summaries shall be signed by the responsible
           Member and made a part of the medical record of that patient.

           A final progress note can take the place of a discharge summary for patients who stay less than forty-
           eight(48) hours and for normal, uncomplicated obstetrical cases and newborns. The final progress note
           must contain all elements of a discharge summary.

3.10       ACCESS TO MEDICAL RECORDS/INFORMATION

           3.10-1     The medical record is the property of the Hospital and is maintained for the benefit of the patient,
                      the Professional Staff and the Hospital.


           3.10-2     The release of medical records and access to medical records shall be governed by Hospital policy,
                      developed in cooperation with the PSEC. Medical records generally cannot be released to
PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11         R 15
                      persons, Practitioners or outside organizations other than the patient unless the patient or his legal
                      representative has provided written authorization for the release of medical information to persons
                      not otherwise authorized to receive this information. Generally, the original medical records may
                      be removed from the Hospital's jurisdiction only with a court order, subpoena (accompanied by
                      written authorization from the patient or legal representative), or State or Federal statute.

           3.10-3     In the case of readmission of a patient, previous relevant records shall be available for the use of
                      the attending Practitioner. This shall apply whether the patient is attended by the same attending
                      Practitioner or another.

           3.10-4     Access to the medical records of all patients shall be afforded to Members for bona fide study and
                      research consistent with preserving the confidentiality or personal information concerning
                      individual patients. Subject to the discretion of the CEO, former Members of the Professional
                      Staff may be permitted access to information from the medical records of patients they attended
                      while a Member.

           3.10-5     Unauthorized removal of records from the Hospital is grounds for suspension of the Practitioner,
                      including health care providers who are under the supervision of a Member. The PSEC shall
                      determine the period of suspension.

3.11       FINAL DISPOSITION OF MEDICAL RECORD

           A medical record shall not be permanently filed until it is completed by the responsible Member or is filed
           as incomplete by order of the VPMA.

3.12       COMPLETION OF MEDICAL RECORDS

           The medical record shall be completed—dictations complete and authenticated— and all entries
           authenticated within 30 days of the patient’s discharge.

3.13       SUSPENSION OF PRIVILEGES

           Discharge summaries shall be completed (dictated and signed) no later than seven (7) calendar days of
           patient discharge. All other medical records shall be completed within twenty (20) calendar days of patient
           discharge. This includes dictated reports, coding queries, Emergency Room T-form diagnoses and all
           signatures. Any discharge summaries not completed by the eighth (8th) calendar day of patient discharge
           and all other records not completed by the twenty-first (21st) calendar day after patient discharge are
           considered “delinquent.”

           The staff privileges of a Professional Staff Member who fails to complete his discharge summary within
           seven (7) calendar days of patient discharge and all other documentation within twenty (20) calendar days
           shall automatically be suspended. This means all admitting, consulting and operative Privileges will be
           withheld until the charts are completed.

           Documentation delegated to an Intern, Resident Physician, or Physician Assistant is also the responsibility
           of the Member. The Member will be suspended if such documentation is not completed within seven (7)
           calendar days of patient discharge for the discharge summary and twenty (20) calendar days of patient
           discharge for all other documentation.

           It is the responsibility of the Member to check the aging status of his records by accessing the Electronic
           Medical Records System. Each deficiency’s aging status is indicated by one of the following categories:
           Incomplete, Warning, Pending Suspension, or Suspension. It is the responsibility of the Member to
           complete his records before they age to a Suspension status (8 days or greater for the discharge summary
           and 21 days or greater for all other documentation).
PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11          R 16
           A Member will be suspended if the Electronic Medical Records System contains any medical record
           deficiencies that have aged eight (8) calendar days for the discharge summary or twenty one (21) calendar
           days for all other documentation.

           If a Member remains on suspension two (2) weeks in a row and/or is on suspension five (5) times during a
           two (2) year calendar period, the Medical Record Administrator will notify the CEO and PSEC. The
           physician will then be required to attend a PSEC meeting to discuss his reasons for the delinquency.
           Special assessments and/or fees may be assigned to the Member by the PSEC.

           A Member’s failure to complete records by the deadline imposed by the PSEC shall be considered the same
           as recommendation to revoke Membership made pursuant to the Resolution Processes Appendix of the
           Bylaws, reported to the Board pursuant to Resolution Processes Appendix and entitle the Member to such
           review procedures as are applicable in the Review Procedures Plan.

                                ARTICLE IV. GENERAL CONDUCT OF CARE
4.1        PATIENT CONSENT FOR TREATMENT

           *4.1-1     Patient consent for medical treatment shall be governed by the Hospital’s written policies
                      developed in cooperation with the PSEC and procedures for the authorization of medical treatment
                      and these Rules.

           4.1-2      A general consent form, signed by or on behalf of every patient admitted to the Hospital, must be
                      obtained at the time of admission.

           4.1-3      Informed consent must be obtained for all invasive procedures, high-risk therapies/drugs, and
                      experimental treatments, except that such consent may be implied in a bona fide emergency or
                      described in surgical consent below. Professional Staff Departmental/Section Rules shall
                      delineate what activities constitute high-risk therapies/drugs as they pertain to their specialty. It is
                      the Practitioner's responsibility to specifically inform and document in the medical record, via a
                      progress note and/or consent form provided by Hospital, his discussion with the patient of the
                      diagnosis, nature and purpose of the care/procedure to be provided, the risks/consequences of
                      care/procedure, feasible alternatives, and the prognosis if no treatment is rendered.

           4.1-4      Surgical Consent

                      An informed consent for surgery shall be a part of the patient's chart before surgery is performed.
                      It must be dated, timed, and signed by the patient and the Practitioner informant. In those
                      situations wherein the patient's life or permanent well-being is in jeopardy and delay in treatment
                      would add to that jeopardy and suitable signatures cannot be obtained due to the condition of the
                      patient, the written and signed informed surgical consent need not be on the record prior to
                      surgery. In emergencies involving a minor or unconscious patient in which consent for surgery
                      cannot be immediately obtained from parents, guardian or next of kin, these circumstances should
                      be fully explained on the patient's medical record.

                      In circumstances where a second operation will be required during the patient's stay in the
                      Hospital, a second consent specifically worded shall be obtained. If two or more specific
                      procedures are to be carried out at the same time and this is known in advance, they may all be
                      described and consented to on the same form.




PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11          R 17
4.2        WRITTEN AND VERBAL ORDERS

           4.2-1      All orders for treatment shall be in writing and shall be signed, dated, and timed by the
                      Practitioner making them. A verbal order shall be considered to be in writing if dictated by a
                      Practitioner to a duly authorized person functioning within his or her sphere of competence and
                      signed by the responsible Practitioner or appropriate member of the House Staff.

                      Verbal orders shall be used infrequently and used as necessary to meet the care needs of the
                      patient when the Practitioner is unable to write the order. All orders dictated over the telephone
                      or given verbally shall be dated, timed and signed by the person to whom dictated with the name
                      of the Practitioner noted before the writer’s name. All orders for treatment shall be in writing and
                      shall be signed, dated and timed, by the Practitioner making them the next time the patient is
                      visited or documents information in the patient’s record, or within forty-eight (48) hours,
                      whichever is sooner.       When the Practitioner who dictated the verbal order is not able to
                      authenticate the order (e.g. the Practitioner who dictated the order is “off-duty”) a covering
                      Practitioner must co-sign the order for the Practitioner. A verbal order can only be counter-
                      signed, dated and timed by an appropriate Attending Practitioner.

           4.2-2      The initiation of no code orders or discontinuation of life support measures shall be governed by
                      Hospital policies. Oral orders for a no code may be taken over the phone by a duly authorized
                      person functioning within his sphere of competence in the following situations:

                      (a)        There is prior documentation in the chart that a discussion has previously occurred
                                 between the patient and/or his family and/or his legal representative and the Practitioner;
                                 or

                      (b)        The patient is a private patient of the attending Practitioner and a pre-admission
                                 discussion has taken place; or

                      (c)        The patient has an advance directive reflecting patient's desires to be a no code. Such an
                                 oral no code order shall reflect prior discussions and/or the language in the advance
                                 directive whichever takes legal precedence. The oral no code order will remain in effect
                                 for twenty-four (24) hours by which time substantiating documentation must be in the
                                 medical record. That documentation shall be:

                                 (i)         A copy of the advance directive, or

                                 (ii)        A copy of no code documentation from another acute care or skilled nursing
                                             facility, or

                                 (iii)       Documentation by the Practitioner of prior discussions with the patient and/or
                                             his family and/or his legal representative.

                                 The phone order must be signed within twenty-four (24) hours. All no code orders must
                                 be reaffirmed by signed order within time frames established by Hospital Policies and
                                 Procedures.

           4.2-3      Orders that cannot be orally dictated will be delineated by the PSEC and available on each
                      Nursing unit.




PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11             R 18
           4.2-4      Specific AHPs may write and give oral orders to the extent designated in the credentialing process
                      and in compliance with stated restrictions or restrictions dictated by Federal or State law.

           4.2-5      Persons Able to Accept and Transcribe Oral Orders

                      Duly licensed ancillary health care professionals employed by the Hospital and AHPs credentialed
                      by the Hospital may accept and transcribe into the medical record oral orders issued by a qualified
                      Practitioner. Such oral orders must be limited in scope to the AHPs specific licensed discipline
                      and/or his credentialed privilege.

                      Ancillary health care personnel may accept specialty-related verbal orders from Practitioners in
                      accordance with established departmental and Hospital policies.

           4.2-6      Orders of non-credentialed practitioners (MD, DO, DDS, DC, DMD, DPM, PA-C, CNM, NP) for
                      ancillary diagnostic or therapeutic tests and studies will be recognized by the Hospital and
                      Professional Staff. IRMC shall provide the appropriate ancillary service to all individuals who
                      present themselves with an order signed by any of those non-staff/non-privileged practitioners.
                      These services may include, but are not limited to, radiology, laboratory, physical therapy,
                      occupational therapy, and speech therapy.

           4.2-7      The Professional Staff delegates to the therapist (physical therapist, occupational therapist, speech-
                      language pathologist), upon an order for therapy, to evaluate the patient, develop a plan of
                      treatment, and initiate the plan of care prior to the physician signing off. The physician will sign
                      the plan as soon as reasonably possible.

4.3        FORM OF WRITTEN ORDERS/RE-WRITTEN ORDERS

           Practitioner orders must be written clearly, legibly and completely. Illegible or improperly written orders
           will not be administered until re-written or understood by the appropriate personnel.

4.4        CONTROL OF DRUG ADMINISTRATION

           4.4-1      All drugs and medications administered to patients shall be those listed in the Hospital Formulary,
                      or formulary of any entity with which the Hospital has contracted for pharmacy services, or any
                      FDA update/advance notice.

                      Exception: Drugs for bona fide clinical investigations may be exceptions. These shall be used in
                      full accordance with the "Statement of Principles Involved in the Use of Investigational Drugs in
                      Hospitals" and all regulations of the FDA, subject to the authorization by the Hospital's
                      Institutional Review Committee.

           4.4-2      Automatic Expiration of Orders

                      (a)        An automatic expiration date shall be observed for all inpatient medication orders unless:

                                 (i)         The order indicates a specific number of doses to be administered.

                                 (ii)        An exact period of time for the medication is specified.

                                 (iii)       The prescriber reorders the medication.

                                 (iv)        The Professional Staff and the Pharmacy and Therapeutics Committee shall
                                             establish time periods for the classes of pharmaceuticals.

PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11              R 19
                                 (v)         The prescriber shall be notified at least twenty-four (24) hours prior to the
                                             designated expiration time at which time the order to continue or discontinue
                                             will be obtained.

                      (b)        All previous medication orders shall be automatically canceled and new orders written
                                 when any patient goes to surgery unless:

                                 (i)         The procedure is diagnostic; and

                                 (ii)        No anesthesia or local anesthesia only, is required; and

                                 (iii)       Performed in the surgical suite because of the availability of necessary
                                             equipment or personnel elsewhere
4.5        CONSULTATIONS

           4.5-1      The attending Practitioner is primarily responsible for requesting consultation when indicated and
                      for calling in a qualified consultant. Any qualified Member credentialed with appropriate clinical
                      Privileges can be called for consultation. Requests for consultations and participation in
                      management shall be recorded on the Practitioner's order sheet. Content of the Consultation
                      Report is governed by Section 3.7 of these Rules.

           4.5-2      Consultation is required in the following situations:

                      (a)        When the patient is critically ill and the clinical condition of the patient is outside the
                                 Privileges and area of expertise of the attending Practitioner.

                      (b)        When the patient is not considered to be a good risk for operation or treatment
                                 contemplated.

                      (c)        When the diagnosis appears to be obscure after ordinary diagnostic procedures have been
                                 completed.

           4.5-3      Except in an emergency, consultation is encouraged in the following situations:

                      (a)        Where there is significant doubt as to the choice of therapeutic measures to be utilized.

                      (b)        In unusually complicated situations where specific skills of other Practitioners may be
                                 needed.

                      (c)        When evidence of a major psychiatric disorder is revealed in a patient who is admitted
                                 for conditions non-psychiatric in nature, a psychiatric consultation is strongly
                                 recommended.

           4.5-4      Consultation Types and Time Frame:

                      (a)        Emergent
                                 Emergent consults shall be completed within a 4-hour period from the time of request.
                                 The physician requesting the Emergent Consult MUST personally contact the consulting
                                 physician to confirm the requested Consultant’s ability to respond within four (4) hours.
                                 If the Consultant is unable, the requesting physician shall find an alternate Consultant to
                                 respond within four (4) hours. Written documentation of the Physician-to-Physician(s)
                                 communication must be present (dated, timed and signed) in the patient’s medical record.


PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11              R 20
                      (b)        Routine
                                 Routine consults shall be completed within a 24-hour period from the time the
                                 consultation request is communicated to the consulting physician/designee.
                                 Consultations within Critical Care Units should be performed within twelve (12) hours by
                                 an intensivist.

           4.5-45     Form of Consultations

                      The attending Practitioner shall clearly indicate one of the following categories of consultation:

                      (a)        Consultation Only
                                 Denotes a request for consultation on a single-visit basis with appropriate documentation.
                                 The consultant would not have authority to write orders or administer therapy.

                      (b)        Consultation and Concurrent Care
                                 Asks for continued assistance and joint coverage of the patient by the attending
                                 Practitioner and consultant, in addition to the documented consultation. Both the
                                 attending Practitioner and the consultant may write orders; however, the overall chart
                                 responsibility remains with the attending Practitioner.

                      (c)        Consultation and Complete Referral
                                 Asks for a consultation and transfer of the patient to the service of the consultant. The
                                 attending Practitioner may no longer write orders for the patient.

4.6        SUPERVISION OF HOUSE OFFICERS

           The services of House Officers are overseen by attending Practitioners in all aspects of patient care.

           4.6-1      Policies are maintained by the Medical Education Committee that outline supervision
                      requirements.

           4.6-2      The Director of Medical Education and Residency/Training Program Directors monitor and
                      confirm appropriate supervision.


                 ARTICLE V. GENERAL RULES REGARDING SURGICAL CARE
5.1        AUTOMATIC CANCELLATION OF SURGICAL PROCEDURE

           Except in life-threatening emergencies, the pre-operative diagnosis, required laboratory tests, confirmation
           of informed consent and history and physical must be recorded on the patient's medical record prior to any
           surgical procedure. Failure to so record may result in cancellation of the procedure unless the attending
           Practitioner states in writing that such delay would be unreasonably dangerous to the patient. The Nursing
           Supervisor on duty shall notify the Chairman of the Department or Section Chairman of the operating
           Practitioner, or his designee, who shall have the authority to cancel a procedure under these circumstances.

5.2        CARE OF GENERAL DENTAL PATIENTS

           The responsibility of the care of dental patients co-admitted by a Dentist and Physician Member shall be in
           accordance with the Bylaws, Section 5.5-5, and in accordance with the Rules of the Department of Surgery.
           Basic responsibilities are as noted.



PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11           R 21
           5.2-1      Dentist’s Responsibilities

                      The admitting Dentist is responsible for the following:

                      (a)        A detailed dental history justifying hospital admission.

                      (b)        A detailed description of the examination of the oral cavity and pre-operative diagnosis.

                      (c)        A complete operative report, describing the findings, technique, and a description of any
                                 discarded, surgically removed specimen, i.e. teeth, fragments.

                      (d)        Progress notes as are pertinent to the oral condition.

                      (e)        Discharge or summary statement.

                      (f)        Notification upon scheduling of admission as to the Physician who will co-manage the
                                 patient.

                      (g)        Obtaining an informed consent (refer to Section 4.1) from patient or legally responsible
                                 person.

           5.2-2      Physician’s Responsibilities

                      The Physician undertaking the co-management of a general dental patient is responsible for:

                      (a)        Medical history pertinent to the patient’s general health.

                      (b)        A physical examination to determine the patient’s condition prior to anesthesia and
                                 surgery.

                      (c)        Supervision of the patient’s general health status while hospitalized.

           5.2-3      Discharge of Dental Patients

                      The general dental patient shall be co-discharged by the Dentist and the Physician Member
                      responsible for the medical management of the patient.

5.3        CARE OF PODIATRIC PATIENTS

           The responsibility for the care of Podiatric patients shall be in accordance with the Bylaws and Rules of the
           Department of Orthopedic Surgery. Basic responsibilities are as noted.

           5.3-1      Podiatrist's Responsibilities

                      The admitting Podiatrist is responsible for the following:

                      (a)        A general history detailing the Podiatric problem and justifying the hospital admission.

                      (b)        A detailed description of the examination of the feet and pre-operative diagnosis.

                      (c)        A complete operative report, describing the findings and technique, and description of
                                 any surgically removed specimen that may be discarded in accordance with Professional
                                 Staff policy.

PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11            R 22
                      (d)        Progress notes as are pertinent to the podiatric condition.

                      (e)        Discharge summary or summary statement prior to discharge.

                      (f)        Notification upon scheduling of admission as to the Physician who shall co-manage the
                                 patient if any.

                      (g)        Obtaining an informed consent (refer to Section 4.1) from the patient or legally
                                 responsible person if any.

                      (h)        If there is no co-management by a Physician, the Podiatrist assumes the duties as
                                 described in Section 5.2-2 and 5.3-2 of these Rules.

           5.3-2      Physician's Responsibilities

                      (a)        Medical history pertinent to the patient's general health.

                      (b)        A physical examination to determine the patient’s condition prior to anesthesia and
                                 surgery.

                      (c)        Supervision of the patient's general health status while hospitalized.


                                      ARTICLE VI. EMERGENCY SERVICES
6.1        PHYSICIAN STAFFING

           The Emergency Department shall be staffed by a qualified Physician Member at all times. Supervision and
           direction of the care rendered in the Department shall be the responsibility of the Chairman of the
           Department of Emergency Medicine.

6.2        MEDICAL RECORD FOR EMERGENCY PATIENTS

           6.2-1      An appropriate medical record shall be kept for every patient receiving emergency service. The
                      record shall ordinarily include:

                      (a)        Adequate patient identification.

                      (b)        Information concerning the time of the patient's arrival, means of arrival, and by who
                                 transported.

                      (c)        Pertinent history of the injury or illness, including details relative to first aid or
                                 emergency care given the patient prior to his arrival at the Hospital.

                      (d)        Description of significant physical, laboratory, and radiological findings.

                      (e)        Diagnosis.

                      (f)        Treatment given.

                      (g)        Condition of the patient on admission, discharge, or transfer.

                      (h)        Final disposition, including instructions given to the patient and/or his family, relative to
                                 necessary follow-up care.
PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11            R 23
                      (i)        Evidence of general and informed consent when applicable as stated in Section 4.1
                                 above. If the patient's condition is life threatening, or there is a risk of permanent harm
                                 and any delay in treatment would significantly add to that risk, the patient's consent is
                                 implied for care and treatment; however, the Practitioner must document evidence of the
                                 patient's condition giving rise to implied consent.

                      (j)        Completed transfer paperwork pursuant to Hospital policies and State and Federal laws if
                                 the patient is transferred to another health care facility.

           6.2-2      Each patient's medical record shall be signed, legible, and completed within twenty-four (24)
                      hours of patient's discharge from the Emergency Department by the Practitioner in attendance that
                      is responsible for its clinical accuracy.

6.3        DISASTER PLANNING

           There shall be a plan for the care of mass casualties at the time of any major disaster, based upon the
           Hospital's capabilities in conjunction with other emergency facilities in the community. The composition
           of a disaster planning committee and the details of the plan shall be defined in the Disaster Plan.

               ARTICLE VII. PROVISIONS FOR USE OF ANESTHETIC AGENTS
7.1        USE OF LEVEL I MEDICATIONS

           Qualified Practitioners shall be permitted to administer anesthetic agents for Level I procedures. Level I
           Privileges shall be defined as the performance of local infiltration anesthesia, topical application, and minor
           nerve blocks.

7.2        USE OF LEVEL II ANESTHESIA MEDICATIONS

           7.2-1      Definition

                      Level II anesthesia medications are those which, under specific conditions, are routinely used to
                      render a patient insensible to pain and emotional stress during surgery or other invasive procedure
                      and which may result in the loss of a patient's protective reflexes. Level II anesthesia is limited to
                      major regional anesthesia and/or intravenous analgesia. These medications include the use of the
                      following medications administered by any route:

                      (a)        Narcotics (Opioids)

                      (b)        Specified barbiturates (Emergency Department only)

                      (c)        Benzodiazepines

                      (d)        Dissociative Agents (Emergency Department only)

                      (e)        Propofol

                      (f)        Chloral Hydrate (Emergency Department and Pediatrics only)

           7.2-2      Designated Areas/Facility Support

                      The following areas within the Hospital are recognized locations where Level II anesthesia
                      medications are routinely used for the purposes herein defined:
PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11           R 24
                      (a)        Surgery - Main Operative Suites

                      (b)        Surgery - Arthroscopic Surgery Center

                      (c)        Endoscopy Unit

                      (d)        Bronchoscopy Procedure Room

                      (e)        Special Studies Unit (Cath Lab)

                      (f)        Radiology Department

                      (g)        Emergency Department

                      (h)        Special Care Units (CICU, Pre/Post Cath Unit)

           7.2-3      Credentialing Responsibility

                      (a)        Department of Anesthesiology.
                                 The Department of Anesthesiology is responsible for privileging of all licensed
                                 Practitioners whose primary clinical activity is the provision of anesthesia services, i.e.,
                                 Members of the Department of Anesthesiology.

                      (b)        Other Professional Staff Departments.
                                 Respective departments of the Professional Staff are responsible for delineating
                                 Privileges for Level II anesthesia as it incidentally applies to the scope of clinical practice
                                 within the department. Such delineation at a minimum shall be medication-specific and
                                 in accordance with the Formulary.

           7.2-4      Medico-Administrative Responsibilities

                      The Chairman of the Department of Anesthesiology, or his designee, shall participate with other
                      Departments/services in the development of mechanisms and material that help to provide uniform
                      quality of anesthesia services throughout the Hospital. These include, but are not limited to, the
                      following:

                      (a)        Mechanisms to confirm anesthesia services are consistent with patient needs and with
                                 current knowledge concerning anesthesia practice.

                      (b)        Type and amount of physical resources required.

                      (c)        Mechanisms to effectively monitor and evaluate the quality of anesthesia services
                                 throughout the Hospital including:

                                 (i)         Anesthesia safety guidelines.

                                 (ii)        Policies relating to operational and interdisciplinary clinical practice as well as
                                             the program for cardiopulmonary resuscitation.

                                 (iii)       Continuing medical education as appropriate.

           7.2-5      Administration

PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11              R 25
                      It shall be the responsibility of the Chairmen of the Department of Anesthesiology and each
                      Department to assure compliance with this policy.

7.3        USE OF ANESTHESIA OUTSIDE THE SCOPE OF LEVELS I AND II

           7.3-1      Credentialing Responsibility

                      Privileges for use of anesthesia medications, which do not fall within the definition of Level I
                      and/or Level II, shall be requested and considered by the Department of Anesthesiology.

           7.3-2      Other Considerations

                      Requests for use of anesthesia medications not currently included on the Hospital’s Formulary will
                      be forwarded to the Chairman of the Department of Anesthesiology for categorical evaluation
                      prior to consideration of the request.

                           ARTICLE VIII. PROFESSIONAL STAFF MEETINGS
8.1        ANNUAL MEETING

           The annual meeting of the Professional Staff shall take place in October. Notice of date, time, and place
           shall be sent to all Members at least fourteen (14) business days in advance.

8.2        REGULAR PROFESSIONAL STAFF MEETINGS

           8.2-1      Regular business meetings shall be held in the months of January, April, and July. Notice of date,
                      time, and place shall be sent to all Members at least fourteen (14) business days in advance.

           8.2-2      Organized Departments must meet at least quarterly to present educational programs and conduct
                      clinical review of practice within the department.

                                ARTICLE IX. DEPARTMENT/SECTION RULES
9.1        DEPARTMENT/SECTION RULES

           Each Professional Staff Department, and Section if applicable, shall establish, through the Department
           Chairman, written rules for the operation of that Department/Section. Such rules are subject to approval by
           the PSEC and the Board.




PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11        R 26
                                 ARTICLE X. ADOPTION AND AMENDMENT

10.1       PROFESSIONAL STAFF RESPONSIBILITY AND BOARD INITIATION

           The principles stated in the Bylaws of the Professional Staff and the Hospital regarding Professional Staff
           responsibility and authority to formulate, adopt, and recommend General Rules affecting the Professional
           Staff, and amendments thereto, and the circumstances under which the Board may resort to its own
           initiative in accomplishing those functions shall apply as well to the formulation, adoption, and amendment
           of the General Rules.

10.2       AMENDMENT

           The General Rules may be amended or repealed, in whole or in part, by the PSEC of the Professional Staff,
           acting on its own initiative or following consultation with the Professional Staff as a whole, subject to the
           approval of the Board.

10.3       ADOPTION

           10.3-1     Professional Staff

                      The foregoing General Rules were adopted and recommended to the Board of Trustees by the
                      PSEC in accordance with and subject to the Bylaws of the Professional Staff.

                      ADOPTED AND APPROVED ON:

                      __________________________
                      DATE
                      ______________________________________
                      CO-CHIEF OF THE PROFESSIONAL STAFF
                      ______________________________________
                      CO-CHIEF OF THE PROFESSIONAL STAFF
                      ________________________________________
                      SECRETARY OF THE PROFESSIONAL STAFF

           13.3-2     Board of Trustees

                      The foregoing General Rules were adopted and approved by resolution of the Board of Trustees
                      after considering the PSEC’s recommendation and in accordance with and subject to the Ingham
                      Regional Medical Center’s Corporate Bylaws.

                      ADOPTED AND APPROVED ON:

                      _______________________________
                      DATE
                      ______________________________
                      CHAIRMAN OF THE BOARD
                      ______________________________
                      SECRETARY OF THE BOARD




PSEC Approved 9/21/2009; 7/25/2011
Professional Staff Approved 10/27/2009
Board of Trustees Approved 11/12/2009
Revision approved 4/20/2010; 1/18/2011; 9/12/11       R 27

								
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